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Nursing Theses and Capstone Projects Hunt School of Nursing
2012
Critical Care Nursing Interventions and Incidenceof Ventilator Associated Pneumonia in the TraumaPopulationKelli R. MooreGardner-Webb University
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Recommended CitationMoore, Kelli R., "Critical Care Nursing Interventions and Incidence of Ventilator Associated Pneumonia in the Trauma Population"(2012). Nursing Theses and Capstone Projects. 135.https://digitalcommons.gardner-webb.edu/nursing_etd/135
Critical Care Nursing Interventions and Incidence of Ventilator Associated Pneumonia in
the Trauma Population
by
Kelli R. Moore
A thesis submitted to the faculty of
Gardner-Webb University School of Nursing
in partial fulfillment of the requirements for the
Degree of Master of Science in Nursing
Boiling Springs
2012
Submitted by: Approved by:
______________________ _____________________
Kelli R. Moore Dr. Rebecca Beck-Little
______________________ _____________________
Date Date
ii
Abstract
Ventilator Associated Pneumonia (VAP) in the Trauma Intensive Care Unit is the most
commonly encountered infection in the intensive care unit and can be linked to increased
morbidity, increased mortality, increased mechanical ventilation days, increased hospital
length of stay, and increased cost. A retrospective, correlational study examined the
effect of compliance with a ventilator bundle protocol in the Neuro-Trauma Intensive
Care Unit on aggregate VAP rates. The study’s primary focus was to determine if
interventions performed by critical care nurses reduced the incidence of Ventilator
Associated Pneumonia (VAP) in the Trauma Intensive Care Unit. The study utilized the
retrospective collection of electronic medical records, trauma registry records, and
hospital epidemiology records of the sample population.
iv
TABLE OF CONTENTS
CHAPTER I
Introduction ..............................................................................................................1
Purpose .........................................................................................................2
Significance..................................................................................................2
Research Question .......................................................................................3
Definition of Terms......................................................................................4
Study Design ................................................................................................4
Theoretical Framework ................................................................................5
CHAPTER II
Literature Review.....................................................................................................9
CHAPTER III
Methodology ..........................................................................................................16
Setting ........................................................................................................16
Sample Population .....................................................................................16
Instruments .................................................................................................17
Ethical Considerations ...............................................................................17
Data Collection Method .............................................................................18
Data Analysis .............................................................................................18
CHAPTER IV
Results ....................................................................................................................19
VAP Occurrence ........................................................................................20
v
CHAPTER V
Discussion ..............................................................................................................23
Significance of Findings ............................................................................23
Implications for Nursing Practice ..............................................................24
Limitations of the Study.............................................................................25
Recommendations for Future Research .....................................................25
Importance of the Findings for Nursing.....................................................25
REFERENCES ......................................................................................................27
vi
List of Tables
Table 1: Ventilator Bundle Compliance over the six quarters ...............................19
Table 2: Ventilator Associated Pneumonia over the six quarters ..........................19
vii
List of Figures
Figure 1: Total Ventilator Bundle Compliance over the six quarters ....................21
Figure 2: Occurrence of Ventilator Associated Pneumonia over the six quarters .21
Figure 3: Rate of Ventilator Associated Pneumonia over the six quarters ............22
1
Chapter I
Introduction
Trauma centers around the country and around the world now recognize the
importance of hospital acquired, or nosocomial infections as they contribute to increasing
morbidity and mortality in hospitalized trauma patients. This increase in morbidity and
mortality results in significantly increased hospital costs. Ventilator-associated
pneumonia (VAP) is the most commonly encountered infection among trauma patients in
the intensive care unit, and has been the focus of substantial efforts in prevention,
diagnosis, and treatment in this challenging patient population (Shorr & Kollef, 2005).
The Centers for Disease Control (CDC) created a National HealthCare Safety
Network (NHSN) primarily to analyze the incidence of various nosocomial infections.
The CDC/NHSN publishes yearly annual reports, which outlines details regarding
specific rates of the various infections, as well as provides an overall benchmark for
infection rates to participating hospitals. The data revealed to researchers that trauma
VAP rates have declined steadily over the past seven years. The VAP rate of 15.2 per
1,000 ventilator days in 2004 reduced to a VAP rate of 8.1 per 1,000 ventilator days in
2009, proves that multi-disciplinary team attention and education surrounding this critical
issue assists in the reduction. Despite the decline in Trauma Intensive Care Unit (ICU)
VAP rates reported by the NHSN, published literature from designated trauma centers
world-wide indicates that VAP rates remain high (Rello, Ollendorf, and Oster, 2002).
Direct care givers in the trauma intensive care have many challenges in caring for
this population, hence the reason to focus on this preventable complication. Prevention
of VAP requires a concerted effort on the part of hospital administrators, physicians, and
2
intensive care nursing staff. Hospital surveillance programs must be evidenced-based,
maintained, updated, and accepted by all direct care givers in the trauma intensive care
unit. Intense focus should be on continued education and feedback to the multi-
disciplinary team, as this is crucial to further reduction of or maintaining a low VAP rate
in the trauma intensive care unit.
Purpose
The purpose of the research study was to determine the effect of interventions
performed by critical care nurses on the incidence of Ventilator Associated Pneumonia
(VAP) in the Trauma Intensive Care Unit. To reiterate, VAP is the most commonly
encountered infection in the intensive care unit, and can be linked to increased morbidity,
increased mortality, increased mechanical ventilation days, increased hospital length of
stay, and increased cost (Rello et al., 2002). Research on interventions can provide
evidence to reduce VAP rates that may be used to educate the multidisciplinary trauma
team on appropriateness of care. This study, to determine the effect of interventions
performed by critical care nurses on the incidence of Ventilator Associated Pneumonia
(VAP), has the potential to yield data that will shape the future development of evidence-
based practice guidelines, decrease the complication of VAP in the Trauma Intensive
Care Unit (ICU), and improve overall outcomes in the trauma population.
Significance
Ventilator-associated pneumonia (VAP) accounts for a large number of
nosocomial infections in the trauma population today (Shorr & Kollef, 2005). Adherence
to evidence based practice guidelines for the prevention of VAP will greatly reduce the
occurrence of this complication in the ICU setting. Most hospitals have implemented the
3
vent bundle at this point (as recommended by the CDC) however, many interpret these
recommendations differently (Institute of Healthcare Improvement (IHI), 2011). Care
guidelines or evidence-based practice orders sets should be agreed upon and used to
direct the care delivery of VAP infections. Bedside staff should be involved in the
development of such guidelines for successful implementation and adherence. A vent
bundle can be defined as a “check list” of clinical interventions that will guide the clinical
team in prevention against ventilator associated pneumonias. This checklist includes
indicators such as appropriate oral care-swabbing of mouth of intubated patients,
chlorhexidine oral rinse, increasing the head of bed in vented patients to greater than 45
degrees if not contraindicated, sedation holidays, deep venous thrombosis prophylaxis,
peptic ulcer prophylaxis, frequent suctioning of endotracheal tube, and frequent hand
washing. More research is needed in this area; ideally by participating in multi-
intuitional studies focused on evidenced based guideline development and variance
tracking. Continued vigilance should be maintained in order to positively impact the VAP
rate in the Trauma Intensive Care Unit (ICU). This quality indicator should be monitored
monthly by the Nurse Manager and Infection Control Specialist with findings shared with
physician providers as well as bedside staff.
Research Question
What is the effect of nursing interventions on the incidence of ventilator
associated pneumonia (VAP) in the trauma intensive care unit?
4
Definition of Terms
The following definitions were used in the study of the effect of interventions
performed by critical care nurses on the incidence of Ventilator Associated Pneumonia
(VAP):
Ventilator Associated Pneumonia (VAP) - pneumonia in a patient intubated and
ventilated at the time of or within 48 hours before the onset of the event.
VAP Rate - the number of ventilator-associated pneumonias, per 1,000 ventilator
days. In this case, for a particular time period, we are interested in the total number of
cases of ventilator-associated pneumonia in the ICU.
Study Design
The study of the effect of interventions performed by critical care nurses on the
incidence of Ventilator Associated Pneumonia (VAP) was a retrospective, observational,
correlational study which examined facility compliance with a ventilator bundle check
list in the Neuro-Trauma Intensive Care Unit and aggregate Trauma ICU VAP rates. The
hospital at which the study was conducted, adopted the Institute for Healthcare
Improvement’s (IHI) ventilator bundle checklist. The primary focus of the study was to
determine if interventions performed by critical care nurses reduced the incidence of
Ventilator Associated Pneumonia (VAP) in the Trauma Intensive Care Unit. This study
design will allow the greatest amount of control possible to examine causality more
closely (Burns & Grove, 2009). In this study, the development of and compliance with a
ventilator bundle check list served to eliminate other factors that may influence the
variables. A data collection tool was developed by the hospital prior to the study of
monitor ventilator bundle compliance in the sample population. This ventilator bundle
5
compliance tool was utilized by the Registered Nurse (RN) case manager during daily
multi-disciplinary rounds.
Theoretical Framework
The theoretical framework selected for this study was based on Roy’s Adaptation
Model (RAM), (2009). Roy is best known for her teaching, scholarly research and
writing related to the development of nursing knowledge and practice. The original Roy
model, developed in 1977, was based on the works of Von Bertalanffy’s general system
theory and Helson’s adaptation theory as forming the original basis of the scientific
assumptions. The assumptions flow from the initial philosophical and scientific
perspectives. The philosophical assumptions were based in humanism perspectives of
creativity, purposefulness, holism, and interpersonal process relating to the RAM
concept. The scientific assumptions were based in systems theory perspectives of holism,
interdependence, control processes, information feedback, and complexity of living
systems relating to adaptation-level theory assumptions that behavior is adaptive,
adaptation is a function of stimuli and adaptation level, adaptation levels are individual
and dynamic, and the processes of responding are positive and active (Roy & Andrews,
1999).
In response to the 25th
anniversary of the model’s publication, Roy restated the
assumptions that form the basis of the model and redefined adaptation. Adaptation is
defined as “the process and outcome whereby thinking and feeling persons, as individuals
or in groups, use conscious awareness and choice to create human and environmental
integration” (Roy & Andrews, 1999).
6
There are four major concepts of the RAM and those are:
1. Humans as adaptive systems as both individuals and groups
2. The environment
3. Health
4. The goal of nursing
According to Roy's model, a person is a bio-psycho-social being in constant
interaction with a changing environment. He or she uses innate and acquired mechanisms
to adapt. The model includes people as individuals, as well as in groups such as families,
organizations, and communities. This also includes society as a whole.
According to Roy (2009), the human adaptive system has inputs of stimuli and
adaptation level, outputs as behavioral responses that serve as feedback, and control
processes known as coping mechanisms. Roy identifies inputs as stimuli and adaptation
level. Stimuli are conceptualized into three classifications: focal, contextual, and
residual. The stimulus most immediately affecting the human system is the focal
stimulus, and demands the highest awareness from the human system. Contextual stimuli
are all other stimuli of the human system’s internal and external worlds that can be
identified as having a positive or negative effect on the situation. Residual stimuli are
external factors whose effects are unclear (Roy, 2009). Along with stimuli, adaptation
level is also an important internal input to the system. Adaptation level is the combining
of all three stimuli that represent the condition of life processes for the human adaptive
system.
For the human adaptive system, complex internal dynamics acts as control
processes. Roy presents a unique nursing science concept of control mechanism. These
7
mechanisms are called regulator and cognator. The transmitters of the regulatory systems
are chemical neural or endocrine in nature. The other control subsystem is the cognator
subsystem. Cognator control processes are related to the bigger brain functions of
perception, information processing, judgment, and emotion. Maximum use of coping
mechanism broadens the adaptation level of an individual, and increases the range of
stimuli to which a person can positively respond.
The Four Adaptive Modes of Roy's Adaptation Model are physiologic needs, self-
concept, role function, and interdependence. The goal of nursing is to promote adaptation
in all the various modes, thus contributing to health, quality of life, and dying with
dignity, by assessing behaviors and factors that influence adaptive abilities and by
intervening to enhance environmental interactions (Roy, 2009).
The nursing process is a decision making method compatible with the practice of
nursing using the RAM. The Adaptation Model includes a six-step nursing process.
After making a behavioral assessment and nursing judgment, nurses assess stimuli
affecting responses, make a nursing diagnosis, set goals, and implement interventions and
evaluate to promote adaptation.
The sequence of concepts in the RAM logically followed the concepts of this
study to determine if interventions performed by critical care nurses reduced the
incidence of VAP in the ICU. In this study, the physiological mode represents the human
system’s physical responses and interactions with the environment, and is defined as a
critically-ill, intubated trauma patient (individual) and total case sample during an 18
month period (group). The RAM’s concept input is considered to be the process of
mechanical ventilation, and is measured by the total case sample during the 18 month
8
period. Nursing intervention is nursing compliance with the ventilator bundle as
measured by the ventilator bundle compliance tool data. Adaptation in this study is the
patient’s response to ventilator assisted respiration or VAP, and is measured by the
occurrence of VAP in a single patient and VAP rates in the total case sample.
9
Chapter II
Literature Review
Prior to conducting the study to determine the effect of interventions performed
by critical care nurses on the incidence of Ventilator Associated Pneumonia (VAP), a
literature review was conducted using the Cumulative Index for Nursing and Allied
Health Literature and EBSCO databases. Keywords included: ventilator bundle,
Ventilator Associated Pneumonia (VAP), and evidence-based guidelines. The following
chapter reports the results of studies found that met the criteria of currency within the
past five years and relative to the study.
A prospective, observational study was conducted by DuBose et al. (2010) at a
busy urban Level I trauma center to examine the effectiveness of the quality rounds
checklist (QRC) in documenting compliance with prophylactic measures for VAP and
other intensive care unit complications. Another goal of this study was to determine if
improvements in compliance with evidence based practices would prove sustainable
beyond the three months of initial examination. The study sample included trauma
patients that were admitted to the ICU longer than 48 hours during the 14 month period
of using QRC. The results of this study indicated that use of a QRC facilitates
sustainable improvement in compliance rates for clinically significant prophylactic
measures in a busy Level I trauma ICU. Daily use of QRC to support compliance with
evidence based endeavors is a sustainable venture that may significantly improve VAP
rates in a busy trauma ICU.
Using a pre-intervention and post intervention observational study design,
Babcock et al. (2004) examined whether an educational initiative with clinical staff could
10
decrease rates of VAP in a regional healthcare system. An educational program
emphasizing correct practice was developed for respiratory care practitioners, as well as
for ICU nursing staff focusing on prevention of ventilator-associated pneumonia. The
program included a self-study module on risk factors for, and strategies to prevent,
ventilator-associated pneumonia and education-based in-services. This study was
conducted in four regional hospitals over a period of three and one half years. Ventilator-
associated pneumonia rates for all four hospitals combined dropped by 46%, from
8.75/1,000 ventilator days in the year prior to the intervention to 4.74/1,000 ventilator
days in the 18 months following the intervention. Educational interventions can be
associated with decreased rates of ventilator-associated pneumonia in the ICU setting.
The study results indicated that involvement of respiratory therapy staff, in addition to
ICU nurses, is important for the success of educational programs aimed at the prevention
of ventilator-associated pneumonia. This finding was consistent with previous research.
Using a two-phase (before and after), prospective, controlled study design,
Quenot et al. (2007) examined whether the use of a nurse-implemented sedation protocol
could reduce the incidence of ventilator-associated pneumonia in critically ill patients.
The study was done in a French university-affiliated, 11 bed medical intensive care unit.
The study sample included patients requiring mechanical ventilation for greater than 48
hours, and who had sedative infusion with midazolam or propofol. Four hundred twenty
three participants were enrolled during the two, 2-year phases, separated by a six month
interval, during which a multidisciplinary team developed the protocol and underwent
training in its use in mechanically ventilated patients. During the first study phase (from
May 1999 to May 2001), no protocol was used (control group). During the second phase
11
(from December 2001 to December 2003), a nurse-implemented sedation protocol was
used (protocol group). During the control phase, sedatives were manipulated according to
the physician’s decision. During the protocol phase, sedatives were manipulated
according to the protocol. Study results revealed the incidence of VAP was significantly
lower in the protocol group compared to the control group. Therefore, the use of a nurse-
implemented sedation protocol decreases the rate of VAP and the duration of mechanical
ventilation.
A controlled, two-group comparison study design was used (Chao, Chen, Wang,
Lee, & Tsai, 2007) to explore the effect of oral secretion on aspiration and reducing
ventilator-associated pneumonia. The subjects used in this study were patients admitted
to a 48 bed general ICU in Taipei city. The control group (n=646) received routine oral
care (patients admitted from September to December). After the control group was
established, the nursing staff was educated regarding the study protocol. The
experimental group (n=574) received oral suctioning before each repositioning (patients
admitted from March to June). Results revealed that VAP was found in 15% of patients
in the control group, and in 4.9% of patients in the experimental group, and that ICU
length of stay and duration of mechanical ventilation was decreased in the experimental
group. This particular study provides evidence that removal of oral secretions before
changing the position of the patient is cost effective in reducing the incidence of VAP.
Using the prospective, randomized study design, researchers (Seguin, Tanguy,
Laviolle, Tirel, & Malledant, 2006) examined the effectiveness of a regular
oropharyngeal application of povidone-iodine on the prevalence of ventilator-associated
pneumonia in patients with severe head trauma. The study was conducted from August
12
2001 to January 2003 in the 21-bed surgical ICU of the University Hospital of Rennes.
The study sample was head injured patients that were expected to need mechanical
ventilation for greater than two days. These patients were prospectively randomized into
three groups: those receiving nasopharynx and oropharynx rinsing with 20 mL of a 10%
povidone-iodine aqueous solution (povidone-iodine group); those receiving nasopharynx
and oropharynx rinsing with 60 mL of saline solution (saline group); or those undergoing
a standard regimen without any instillation, but with aspiration of oropharyngeal
secretions (control group). Within these three groups, a total of 28 cases of ventilator-
associated pneumonia were diagnosed. There was a significant decrease in the rate of
ventilator-associated pneumonia in the povidone-iodine group when compared with the
saline and control groups (three of 36 patients [8%] vs. 12 of 31 patients [39%] and 13 of
31 patients [42%]). The length of stay and mortality in the surgical intensive care unit
were not statistically different between the three groups. This study was designed to test
the hypothesis that povidone-iodine would reduce the prevalence of VAP in head trauma.
In regard to previous studies reporting the prevalence of VAP in head trauma patients, it
was calculated that 30 patients in each group would provide a reduction in the prevalence
of VAP from 50% to 20%. Major findings of this study revealed the regular application
of povidone-iodine, as an oropharyngeal rinse in patients with severe head trauma,
reduced significantly the incidence of VAP when compared with standard care however,
the efficacy of this strategy must be evaluated in other intensive care units. This finding
was consistent with previous research.
A prospective, multi-centered design was used to determine the effectiveness of
semi-recumbent positioning in the prevention of VAP (Van Nieuwenhoven et al., 2006).
13
The study was conducted from January 1999-December 2000 and included patients
admitted to four ICUs in three university hospitals in the Netherlands. An inclusion
criterion was patients intubated within 24 hours of ICU admission with an expected
duration of ventilation of at least 48 hours. Patients in the sample group were randomly
assigned to the semi-recumbent position, with a target backrest elevation of 45°, or
standard care (i.e., supine position) with a backrest elevation of 10°. Of the sample group,
109 patients were assigned to the supine group and 112 to the semi-recumbent group.
Van Nieuwenhoven et al.(2006) found that target semi-recumbent position of 45° was not
achieved for 85% of the study time, and these patients more frequently changed position
than supine-positioned patients. VAP was diagnosed in 6.5% in the supine group and
10.7% in the semi-recumbent group. There were no differences in numbers of patients
undergoing enteral feeding, receiving stress ulcer prophylaxis, developing pressure sores,
in mortality rates, or duration of ventilation and intensive care unit stay between the
groups. The achieved difference in treatment position did not prevent the development of
VAP. This finding was similar to previous research.
A non-experimental, concurrent, observational design study was conducted by
Cocanour et al. (2006) to examine ways in which the multi-disciplinary team in the
Surgical Trauma Intensive Care Unit (STICU) could decrease the incidence of VAP from
occurring in their 20 bed unit. The sample included patients that were admitted to the
STICU from November 2002- June 2003. A ventilator bundle that incorporates the
Center for Disease Control (CDC) Guidelines for Prevention of Nosocomial Pneumonia
was instituted in June of 2002 after VAP rates at this particular hospital reached the
National Nosocomial Infection Surveillance (NNIS) 90th percentile. In October 2002, an
14
intervention, that audited compliance with the ventilator bundle and provided real-time
feedback to ICU staff, was started. Results revealed that VAP did not decrease with
institution of the ventilator bundle alone. However, VAP did significantly decrease when
the ventilator bundle was audited daily and concurrent feedback was shared with
caregivers. Study results have implications for the entire multi-disciplinary team. The
program must be evidence-based, maintained, and accepted by ICU personnel. Continued
education and staff feedback are essential to maintaining a low VAP rate. This finding
was consistent with previously reviewed research.
Using a systematic review design, Zilberberg, Shorr, and Kollef (2009) examined
the literature to determine the effectiveness of the ventilator bundle to prevent VAP.
Studies utilizing the intensive care unit with intubated patients were reviewed. The
systematic review found only four studies with a number of issues. According to these
researchers, problems exist with the design, flaws in the reporting and results of the
studies, including bias. In conclusion, to assure efficient allocation of healthcare
resources, rigorous evaluation of optimal strategies for VAP prevention is needed to
establish best practices. The review found vent bundle is not a viable quality measure in
the intensive care unit at this time. This finding was not consistent with previous
research.
The review of the literature revealed research on the effect of rounding semi-
recumbernt positioning, (Van Nieuwenhoven et al., 2006), povidone-iodine application
(Seguin et al., 2006), oral suctioning (Chao et al., 2007), sedation (Quenot et al., 2007),
and education (Babcock et al., 2004). Results of research on the effect of ventilator
bundling (Cocanour et al., 2006; Zilberberg et al., 2009) were found to be inconsistent. A
15
review of the literature regarding interventions to reduce the incidence of VAP revealed a
gap in the literature, which warrants additional study to determine if interventions
performed by critical care nurses can reduce the incidence of Ventilator Associated
Pneumonia (VAP).
16
Chapter III
Methodology
The study to determine the effect of interventions performed by critical care
nurses on the incidence of Ventilator Associated Pneumonia (VAP) in the Trauma
Intensive Care Unit was a retrospective, observational, descriptive study.
Setting
The study to determine the effect of interventions, performed by critical care
nurses on the incidence of VAP, was conducted at a large regional tertiary medical center
in Western North Carolina. This hospital is a 756 bed, level II trauma center admitting
approximately 3,200 trauma patients annually. The hospital has approximately 7,000
employees and sustains a hospital census on average of 85%. The primary study setting
was in a combined Neurosurgical and Trauma intensive care unit which has 16 staffed
beds. Staffing in this unit consists of only registered nurses and certified nursing
assistants that provide support to RNs. This specialty intensive care unit’s census has an
average occupancy rate of 96%. Patients admitted to this unit are either critically injured
trauma patients or patients with serious neurological conditions that require intense
monitoring by the care team.
Sample Population
The sample for the study to determine the effect of interventions, performed by
critical care nurses on the incidence of VAP, included all patients admitted to the ICU
from January 2011 to June 2012. A retrospective chart review was done to collect data
regarding ventilator days, compliance with vent bundling, and incidence of VAP.
17
Inclusion criteria for the study included:
1. Patient hospitalized with blunt or penetrating trauma from January 2011- June
2012
2. Adult (16 or over)
3. Confirmed diagnosis of VAP
4. On mechanical ventilation longer than 48 hours prior to VAP diagnosis.
No one was excluded from the study based on race or gender.
Instruments
The Ventilator Bundle Check List (VBCL) was developed by the healthcare
facility to monitor ventilator bundle compliance in the sample population. The use of the
VBCL was established previous to the study. Data was collected by the healthcare facility
from reports from the RN case manager, who monitored RN compliance with the
ventilator bundling during daily multi-disciplinary rounds.
Ethical Considerations
Prior to conducting the study to determine the effect of interventions performed
by critical care nurses on the incidence of VAP, the researcher obtained permission from
the Internal Review Board (IRB) for the University, as well as from the healthcare
facility. In the analysis phase, all data was stripped of patient identifiers and was reported
in aggregate. The data collected was entered by the researcher into a secure, password
protected database created and maintained by the researcher. All patient identifiers were
removed from the data prior to entry into the database and reported as aggregate data
only.
18
Data Collection Method
This study consisted of a retrospective collection and review of electronic medical
records, trauma registry records, and hospital epidemiology records for the sample
population, as well as review of the data collection tool for the Neuro-Trauma Intensive
Care Unit ventilator bundle compliance.
Data Analysis
Data was entered into a personal computer by the primary researcher. Descriptive
statistics were performed utilizing the Statistical Package for the Social Sciences, Version
19. Frequencies and measures of central tendencies were performed to determine the
effect of interventions performed by critical care nurses on the incidence of Ventilator
Associated Pneumonia (VAP) in the Trauma Intensive Care Unit.
19
Chapter IV
Results
The sample for the study to determine the effect of interventions performed by
critical care nurses on the incidence of VAP included 1,987 ventilated patients in the
Neuro-Trauma intensive care unit. The study duration was 18 months (January 2011-
June 2012). Aggregate data related to ventilator bundle compliance and ventilator
associated pneumonia per quarter for the 18 months of the study period can be found in
Table 1 and 2 below.
Table 1
Ventilator Bundle Compliance over the six quarters.
Compliance Indicators 1st Qtr
2011
2nd Qtr
2011
3rd Qtr
2011
4th Qtr
2011
1st Qtr
2012
2nd Qtr
2012
Head of Bed elevated 324 337 450 433 252 186 Peptic Ulcer Disease Prophylaxis 320 336 444 432 250 176 Deep Vein Thrombosis Prophylaxis 323 337 448 432 252 177 Sedation holiday 321 333 441 420 254 187 Oral care 319 338 422 410 242 186 Total number of vented patients 324 338 450 433 255 187 Total number compliant with all indicators 316 329 416 395 236 176 Percent total compliance 97 97 92 91 93 94
Table 2
Ventilator Associated Pneumonia over the six quarters.
1st Qtr
2011
2nd Qtr
2011
3rd Qtr
2011
4th Qtr
2011
1st Qtr
2012
2nd Qtr
2012
Number of VAP occurrences 3 1 3 2 2 3 Number of Ventilator Days 631 516 580 685 427 458 VAP Rate (Number of VAP/Ventilator
Days x 1000) 4.75 1.94 5.17 2.92 4.68 6.55
20
VAP Occurrence
It is important to note that all five of the compliance indicators must be performed
in order to be compliant with the ventilator bundle, as determined by IHI’s “all or none”
definition. Ventilator Bundle Compliance was overall quite good during the study
period, varying from 91-97% compliance. Results of data analysis revealed that each
quarter the ICU unit exceeded the target, as determined by their institutional quality and
safety committee. Each individual indicator of compliance was also analyzed to identify
where staff had improved the most during the course of the study. Results showed that
nursing staff was least compliant with oral care, only completing this 96% of the time.
Staff was slightly more compliant with providing a sedation holiday for affected patients
and documenting this occurrence (98.4%), providing peptic ulcer disease prophylaxis
(98.5%), and providing deep vein thrombosis prophylaxis (99.1%). The indicator the
staff was most compliant with was elevating the head of the bed (99.7%). There were five
patients hospitalized in the ICU during the study period, whose clinical condition
warranted the HOB to remain flat. PUD indicator was followed 98.5% of the time.
During the six quarters or 18 months of the study, adherence to the ventilator bundle
checklist was extremely good for this unit, as the institutional established threshold was
90%. (Figure 1)
VAP occurrence over the study period ranged from one to three per quarter
(M=2.33, SD=.81). , averaging 2.33 per quarter. (Figure 2) The number of days patients
were artificially ventilated ranged from 427 to 685 per quarter (M = 549.5, SD = 100.43).
The VAP rate was determined by dividing the incidence of VAP by the number of
21
ventilated days multiplied by 1000. During the study the VAP rate per quarter ranged
from 1.94 to 6.55 (M=4.33, SD=1.65). (Figure 3)
Figure 1. Total Ventilator Bundle Compliance over the six quarters.
Figure 2. Occurrence of Ventilator Associated Pneumonia over the six quarters.
88
90
92
94
96
98
1st Qtr 2011
2nd Qtr 2011
3rd Qtr 2011
4th Qtr 2011
1st Qtr 2012
2nd Qtr 2012
Ventilator Bundle Total Compliance
Percent total Compliance
0
0.5
1
1.5
2
2.5
3
3.5
1st Qtr 2011
2nd Qtr 2011
3rd Qtr 2011
4th Qtr 2011
1st Qtr 2012
2nd Qtr 2012
Neuro Trauma ICU VAP case count
ICNT VAP
22
Figure 3. Rate of Ventilator Associated Pneumonia over the six quarters
0.00
2.00
4.00
6.00
8.00
1st Qtr 2011
2nd Qtr 2011
3rd Qtr 2011
4th Qtr 2011
1st Qtr 2012
2nd Qtr 2012
Neuro Trauma ICU VAP Rate (# VAP/Ventilator Days*1000)
ICNT VAP Rate (# VAP/Ventilator Days*1000)
23
Chapter V
Discussion
Significance of the Findings
The primary aim of this study was to determine effects of nursing interventions on
the incidence of ventilator associated pneumonia (VAP) in the trauma intensive care unit.
The duration of the study was six quarters or 18 months. The study was isolated to a
combined Neurosurgical/Trauma Intensive Care Unit in Western North Carolina. As a
reporting convenience, the researcher analyzed quarterly data instead of monthly data.
The study period was from Quarter 1 of 2011 and ended after Quarter 2 of 2012.
IHI’s “All or none” compliance concept was adopted for purposes of this study
(e.g., Registered Nurses must be compliant with all indicators of the ventilator bundle for
compliance to occur). Throughout the study, ventilator bundle compliance varied from
91% to 97% compliance. Quarterly compliance decreases after the 2nd
Quarter in 2011
due to RN turnover in this particular unit and the use of traveling staff nurses. Significant
educational initiatives were launched after leadership noted non-compliance with this
particular checklist, and other evidence based guidelines pertaining to this patient
population. As of the 2nd
Quarter in 2012, ventilator bundle compliance had increased to
94% compliant. VAP occurrence fluctuates during the reporting period from only one
confirmed VAP case to three confirmed VAP cases. Consequently, it was only during
the 2nd
quarter of 2011 that low VAP occurrence coincided with high ventilator bundle
compliance. VAP occurrence variation is noted throughout the remaining study period.
Although it cannot be proven with this data, it may be suggested that the ventilator
bundle may in fact be suppressing VAP infectious rates in this particular unit. Additional
24
research would be beneficial to determine effectiveness of these interventions on VAP. It
may also be beneficial to “uncouple” the bundle to determine effectiveness of each
individual indicator.
Although VAP has multiple risk factors, nursing interventions and continued
hyper vigilance can possibly reduce the incidence of this disease.
Implications for Nursing Practice
The effects of VAP on morbidity, mortality, length of hospital stay, and cost are
enormous. Education plays a key role in the management of patients with VAP. Nursing
management/leadership should consider utilization of self-study education modules on
the nursing care of patients at risk for VAP as research has indicated it can decrease the
rate of this type of pneumonia as well as decrease the number of days of mechanical
ventilation.
Nursing leadership should be responsible for ensuring appropriate education is
provided as needed to new caregivers. Managers and supervisors should also verify that
ventilator bundle checklists and compliance protocols are completed and appropriately
followed to prevent VAP and other complications of intubation and mechanical
ventilation. As evidenced by the data presented, a simple, yet cost-effective way to ensure
elevation of patient head of bed and other indicators on ventilator bundle compliance
checklist is through daily nursing audits. An “all or none” approach was taken in the
study facility, which essentially means if all ventilator bundle indicators are not followed,
the care team is non-compliant. Standardized orders or pathways proved to be friendly
reminders to healthcare providers about the importance of interventions to prevent VAP
in this setting.
25
Limitations of the Study
There were no known limitations to this study. Generalizability was restricted
given the study was performed in a single neurosurgical-trauma intensive care unit.
Study assumptions included:
The Sample represented the population being studied
Ventilator bundle compliance check lists were completed daily
Recommendations for Future Research
There is clearly a need for a follow-up study, given the many challenges
encountered during this 18 month period with staff turnover and utilization of traveling
staff nurses. It is recommended that the study be replicated in a more stable unit over a
longer period of time.
Importance of the Findings for Nursing
VAP, although often preventable, has a large impact on morbidity and mortality.
Nurses play a key role in preventing VAP. Many of the interventions are part of routine
nursing care. Education for all healthcare providers should focus on the risk factors for
VAP and on preventive measures. In order to further decrease the incidence of VAP,
protocols and monitoring tools must be developed and followed. Several opportunities to
reduce the incidence of VAP are immediately available to the clinician. Many are no-cost
or minimal-cost interventions, and should be implemented as part of routine care
protocols as outlined above. VAP increases patients' care time, length of stay, and
morbidity rate. Consequently, all these negative impacts will increase the health care
costs. Since intubated patients are having a high risk of acquiring VAP, preventive
measures are the key. Care of the critically ill should be directed at applying interventions
26
that reduce mortality, minimize morbidity, shorten the length of stay, and reduce cost.
Reducing VAP through the simple measures does exactly that. It is recommended that the
clinician's practice include; elevation of the head to at least 30°, minimization of sedation,
sedation vacations, administration of a proton pump inhibitor when prophylaxis is
indicated, deep venous thrombosis prophylaxis when indicated, oral care as described
above, and of course excellent hand hygiene. VAP is not a new diagnosis. Education
and research on the prevention of this life-threatening problem should be ongoing in
order to improve overall quality by reducing future morbidities, mortalities, length of
stay, and hospital cost.
27
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